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Pakistan accounts for 44% of all TB cases in the WHO's Eastern Mediterranean region |
Safdar
Ali, 45, is not a tuberculosis (TB) patient, but for the past five years he has
been suffering from the disease because he has to bear the cost of the treatment
that has hit four persons of his 12 member family including his wife,
17-year-old son, 15-year-old daughter and now his youngest six-year-old
daughter.
Living
in a slum of Rawalpindi city, Safdar is a daily wager, who in the best of months
earns up to 3,000 rupees (US $50), barely enough to meet the basic needs of the
family.
TB
has just added an extra burden, as he has to bear, in addition to the cost of
treatment, the bus fare to and from the hospital, and with the additional burden
of not working when he has to take the ill family member to the hospital.
Poverty
coupled with malnutrition has made his family members easy prey to the disease,
one after the other. TB breeds on poverty, and in Pakistan
one third of Pakistan’s 143 million population lives below the poverty line.
Pakistan: TB Breeding Ground
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TB is transmitted through spread of infectious droplets. One cough could produce 3,000 droplet nuclei
Copyright - WHO/P. Virot |
The
country ranks sixth on the World Health Organization's (WHO) list of
high-disease burden countries and accounts for 44 percent of all TB cases in the
WHO's Eastern Mediterranean region.
The
2003 World Health Report of the WHO records that the annual incidence of TB
cases in Pakistan is a whooping 171 per 100,000 persons. Each year, at least 268,000 new cases
are added to the existing patient population of around 1.8 million.
Every
year TB kills 64,000 people in the country causing 26 percent of the deaths that
could be avoided through treatment. Most patients fall in the productive age
ranging between 15 and 45, with half of the percentage being women.
Hassan
Sadiq of the TB Control Programme says that TB bacilli traveling through the air
can easily infect the poor, especially the malnourished, who are hit
particularly severely by the disease.
Transmission
of TB occurs by airborne spread of infectious droplets. The source of infection
is a person with pulmonary TB who is coughing. An estimated 80% of the TB cases
are pulmonary. Coughing produces tiny infectious droplets –one cough could
produce 3,000 droplet nuclei.
TB
was once thought to be diminishing particularly in the West and led to global
complacency to the extent that even medical research in Western countries was
neglected.
But
after the emergence of AIDS (Acquired Immune Deficiency Syndrome) it has
regained attention as TB and AIDS active together are deadly co-partners and
people living with AIDS have a 30 times greater chance of contracting TB. It was
in 1993 that the WHO announced a global emergency to control the deadly
combination.
Pakistan
Places Hope in DOTS
TB
can be cured through DOTS (Directly Observed Short Course); developed after a
large amount of research was conducted in South Asia. DOTS has been successful in controlling TB even in developing countries.
Its
basic principle is diagnosis through sputum microscopy followed by a 6-8 month
treatment plan that involves daily intake of medicine under the supervision of a
health professional, the patient’s neighbor or some elder of the locality
until the patient reaches full recovery.
As
per the WHO, DOTS strategy is to have universal coverage by 2005 -- the target
being that 70% of new severe positive cases are detected, 85% of whom are to be
cured, and that the TB mortality be reduced by 50%.
Officials
in the TB control programme of Pakistan
say that it has also adopted the DOTS strategy with an aim at controlling the
disease through achieving an enhanced 85% cure rate and a 70% detection rate.
They claim that DOTS coverage has been extended to half of the 100 districts of
the country.
However,
independent public health managers warn that the strategy must be extended to
the whole country with full force. It should be supported by a continuous supply
of medications and trained medical experts to correctly diagnose the disease.
This in addition to patients who must be sensitized to complete the programme
without leaving it half way.
Resisting
Treatment
Lapses
in the treatment could result in MDR (Multi Drug Resistant) TB. If a
patient leaves the treatment half way he or she could develop resistance to some
of the drugs used like rifampicin, isoniasid, etc.
Still,
four out of five patients in
Pakistan
remain undetected or untreated. Poor management of this infectious disease,
which includes lack of proper diagnostic equipment and skills, irrational
prescription and non-availability of essential anti-tuberculosis drugs are among
the major contributing factors to Multi-Drug Resistance (MDR) Tuberculosis.
And
this is exactly what is happening in the country. The prevalence of MDR-TB is
quite high.
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The majority of TB patients in Pakistan are poor and can't afford medication |
Similarly,
if the cost of the normal treatment of TB is around Rs 5,000 ($90), in case of
MDR it reaches as high as Rs. 250,000 ($5,000) -- simply unaffordable for the
patients, the majority of whom are poor.
A
study conducted in September of last year by doctors of the Institute of Chest
Medicine of the King Edward Medical College of Eastern Lahore on 100 patients
(68 men and 32 women) suffering from pulmonary TB found that 36% of the
bacterial isolates were resistant to one or more drugs.
Fourteen
percent of the isolates showed resistance to one drug, 13% to two drugs,
5%
to three drugs and 4% to all four of the drugs. Multi Drug Resistance (MDR),
defined as resistance to both rifampicin and isoniazid was present in 11% of the
isolates.
Overall
resistance to individual drugs was: isoniazid 25%, streptomycin 19%, rifampicin
15% and ethambutol 12%.
Previous
exposure to anti-tuberculosis drugs emerged as the most important factor
associated with drug resistance,
especially MDR-TB.
Proper
Training of Medical Professionals Required
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According to one study, only one in 10 GPs in Karachi know how to prescribe correct anti-TB treatment |
The
present national infrastructure of health facilities with 906 hospitals, 4590
dispensaries, 550 rural health centers, 5308 basic health units and 98,264
hospital beds compare well with other developing countries. But the availability
of one doctor per 1466 persons is a poor indicator.
Tuberculosis
control is primarily the responsibility of the public sector, which has not been
working effectively for years. Due to flaws in the governmental health
infrastructure in Pakistan, a large number of tuberculosis patients in both
rural and urban areas visit private clinics run by general practitioners (GPs)
and consultants.
Around
80 percent of the patients suffering from TB first go to a doctor working in the
private sector, but many studies show that they are not trained well enough to
treat a TB patient and might be contributing towards the spread of MDR-TB.
A
study carried out at Agha Khan University revealed that only one in 10 GPs in
Karachi
knew how to prescribe correct anti-tuberculosis treatment. Another study in Karachi
also took into account the same phenomenon highlighting that six out of seven
doctors did not know how to write a rational diagnosis for a detected
tuberculosis patient.
A
similar study by the Network for Consumer Protection (a Non-Governmental
Organization) analyzed the prescription of 53 GPs - four (7.5 percent) were
working in the public and 49 (92.5 percent) in the private sector.
Out
of a total 53 prescriptions, 17 did not mention the age of the patient while
only 10 weighed the patient. Seven doctors mentioned the patient's gender and
three inquired about the patient's and his family's history of tuberculosis. On
seven prescriptions, vital signs and symptoms were mentioned. Although all the
practitioners handed over the prescription to the patient, no record was kept
with them for follow-up and they failed to do any categorization of the disease.
Only 13 asked the patient to come for follow-up and advised a date for the
visit.
Out
of the 53 prescriptions, only two (3.8 percent) practitioners fulfilled criteria
laid down in the National Guidelines for Tuberculosis Control, that also
included pyridoxine in correct dose and frequency. Forty-four practitioners (83
percent) favored a combination drug for the treatment dosage, timing and
duration of therapy.
Pyridoxine,
an important supplement of the treatment was correctly prescribed by only two
practitioners (3.8 percent).
None
of the nine doctors who favored multiple drugs could write the proper dosage and
frequency of the prescribed medicines. Thirty-seven (69.8 percent) practitioners
recommended drugs other than anti-tuberculosis medications, while 16 (30.2
percent) prescribed anti-tuberculosis drugs.
Considering
the prescriptions that contained a proper dosage regimen and frequency of
medicines, only four (seven percent) mentioned other supporting information on
signs and symptoms as well as the weight of the patient and age.
Azhar
Hussain of the Network, a health rights group working to promote the rational
use of medicines, told IslamOnline.net that tuberculosis is an infectious
disease which, if treated badly, not only affects the health of people, but also
puts an alarming burden on the national resources.
He
pointed out the importance of raising levels of awareness on a mass scale and
sensitization of the community at large. He further added that, “Not only GPs,
but pharmacists' roles should be extended and enhanced to address larger and
wider public health needs. Other stakeholders should be involved in this
effort so that disease burden could be lessened at all levels from the
individual to global.”
* Nadeem Iqbal is a freelance journalist based in Islamabad,
Pakistan. Your emails will be forwarded to him by contacting the editor at: ScienceTech@islam-online.net
